practice questions

Question 1

A patient with bulimia nervosa is most likely to have what lab findings…

Answer 1

hypochloremia with subsequent hypokalemia due to renal compensatory mechanisms

hypomagnesemia

metabolic alkalosis

Question 2

What lab findings would you expect to find in a patient with alcohol abuse?

Answer 2

elevated MCV (alcoholics often have create defective RBCs that are destroyed prematurely, possibly resulting in anemia)

increased Triglycerides

increased serum uric acid

increased LFTs

Question 3

a 20 yo male presents to the ED with complains of palpitations and agitation, which developed suddenly while attending a party. on exam, patient is moderatly agitated and tremulous. Vitals include 110 HR, RR 22, BP 160/92. Skin is diaphoretic and pupils are dilated. Which of the following is the most likely diagnosis?

Answer 3

cocaine use

cocaine as well as amphetamines leads to a clinical picture of increased sympathetic stimulation and dilated pupils

Question 4

What kind of clinical picture does heroin produce?

Answer 4

opioids, such as heroin produce euphoria, drowsiness and constricted pupils.

severe intoxication causes bradycardia, respiratory arrest, and hypotension.

Question 5

a 53 yo man with. a history of HTN is being treated with atenolol. He currently presents complaining of chronic fatigue, insomnia, decreased appetite and difficulty concentration for the past 3 weeks. His wife also notes that he no longer goes bowling with his friends and has lost interest in any sexual intimacy. PE is unremarkable. Which is the most likely diagnosis?

Answer 5

major depression–includes a loss of pleasure in usual activities, vegetative or physical changes (poor appetite, loss of energy), and cognitive changes such as difficulty concentration

(dysthmic disorder is a chronic depressive disorder whose symptoms are milder, but longer lasting (> 2 yrs) than those in a major depressive episode)

• (Atypical depression is characterized by hypersomnia, overeating, lethargy, and rejection sensitivity)*
• (while blockers may cause fatigue and sleep disturbances, they do not cause a depressive disorder)*

Question 6

Rates of alcohol use in the adolescent are reportedly higher in:

a. families with rigorous parental monitoring

b. Japanese families

c. adoptive children whose biological parent is an alcoholic

d. mood disorders in a grandparent

Answer 6

adoptive children whose biological parent is an alcoholic

there is a 3 - 4fold increase in risk for alcohol dependence in adopted children whose biological parents are alcohol dependents

Question 7

A patient presents within one hour of ingesting 30 tablets of diazepam (Valium). Which of the following is the most appropriate intervention?

Answer 7

Gastric Lavage

along with administration of activated charcoal and monitoring of vital signs and CNS status is the mainstay of therapy in the person who has OD’ed on benzodiazpenies.

Vomiting should be induced in the person who is not comatose. Flumazenil (ROMAZICON) a specific benzo antagonist, might be used with caution in certain patients.

Question 8

The most important initial component of evaluating a patient with depressive illness is…

Answer 8

assessment of suicidal risk

2/3 of all depressed patients contemplate suicide, and 10 - 15% commit suicide.

Question 9

Which of the following antipsychotic medications is associated with significant agranulocytosis but not with extrapyramidal side effects?

a. clozapine (CLOZARIL)

b. Haloperidol (HALDOL)

c. chlorpromazine (THORAZINE)

d. fluphenazine (PROLIXIN)

Answer 9

clozapine (CLOZARIL)

clozapine is referred to as an “atypical” antipsychotic agent. It can cause agranulocytosis and should be monitored with weekly CBC. This is not a first line treatment drug.

Question 10

Which of the following is a long-term treatment for panic attacks?

a. triazolam (HALCION)

b. propranolol (INDERAL)

c. lorazepam (ATIVAN)

d. fluoxetine (PROZAC)

Answer 10

fluoxetine (PROZAC)

SSRIs such as fluoxetine, are the initial drugs of choice for the long-term treatment of panic disorders.

Question 11

Phenothiazenes exert their antipsychotic effects by blocking…

Answer 11

dopamine receptros

blockage of DA receptors in the mesolimbic areas of the brain is responsible for the antipsychotic effects of phenothiazenes; blockage of DA receptors in the nigrostriatal areas lead to the motor side effects, such as dystonia and akathisia.

• (phenothiazene blockage of alpha-adrenergic and histamine receptors lead to orthostatic hypotension, sedation, and anticholinergic effects)*
• (chlorpromazine, fluphenazine, etc.)*

Question 12

17 yo patient presents to the ED with agitation and hallucinations, and has one seizure. He admits to using “some drugs” but does not know what they were. On PE, temperature is 103, BP 140/90, HR 120, RR 20. Remainder of exam is unremarkable. What is the diagnostic study that will be most helpful in managing this patient?

Answer 12

serum creatinine kinase

• serum creatinine kinase is most sensitive test to detect rhabdomyolysis, a serious complication of seizures and hyperthermia related to drug abuse.*
• although a drug screen may ID specific drugs, the results will not alter*
• the patient is at risk for myoglobinuria, and a dipstick and CBC will not alter the treatment*

Question 13

What is first-line therapy for schizophrenia?

Answer 13

Olanzapine (ZYPREXA)

Initial pharmacologic therapy of schizophrenia should begin with one of the newer, “atypical” antipsychotics, such as olanzapine, risperidone, quetiapine, ziprasidone because their SE profile is significantly better than older drugs, and they may be more effective for negative psychotic symptoms.

Question 14

a 25 yo female graduate student presents to the student health center for the 8th time in 3 weeks to be sure she does not have meningitis. she read that there was a student on campus who had meningitis last month, and now she has HAs and is requesting to be tested to make sure she does not have meningitis. She has been evaluated at each visit and PE has been completely normal each time. What is her most likely diagnosis?

Answer 14

somatic symptoms disorder

some previously distinct somatic disorders—somatization disorder, undifferentiated somatoform disorder, hypochondriasis, and somatoform pain disorder—are now considered somatic symptom disorders. All have common features. These syptoms may or may not be associated with another medical problem; symptoms no longer have to be medically explained. Sometimes the symptoms are normal body sensations or discomfort that do not signify a serious disorder. Patients are commonly unaware of their underlying mental problem and believe that they have physical ailments, so they typically continue to pressure physicians for additional or repeated test and treatments even after results of a thorour evaluation have been negative.

Question 15

What medication used in the management of anxiety has a delayed onset of action?

a. buspirone (BUSPAR)

b. diphenhydramine (BENADRYL)

c. lorazepam (ATIVAN)

d. butalbital (FIORINAL)

Answer 15

buspirone takes several days to weeks for it to have clinical activity

• diphenhydramine works as a histamine blockers and will cause sedation immediately because of its anticholinergic effects*
• lorazepam is an anxiolytic medication that has an immediate onset of activity*
• butalbital is a short to intermediate-acting barbiturate that has immediate activity*

Question 16

A 26 yo female arrives to ED with friends who say she was standing in front of her church, dressed in a white bathrobe, claiming to be the Virgin Mary and hanging out $100 to all passers-by. Her friends noted that she had been depressed lately, but now seems completely euphoric. She had similar episode two years ago. Which of the following is the most appropriate treatment?

Answer 16

inpatient olanzapine (ZYPREXA) therapy

treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.) Lithium, valproate, and olanzapine are considered effective in the manic stage; the depressive stage is treated with antidepressants.

Question 17

a 48 yo alcoholic, whose last drink was 6 days ago, presents to the clinic complaining of palpitations and intermittent abdominal pain. on PE, BP is 170/110 mmHg, pulse 124 bpm, RR 22/min, and T 100.4 degrees F. Patient is agitated and excitable. Cardiovascular exam reveals tachycardia without murmurs, gallops, or rubs, and is otherwise normal. Which of the following is the most appropriate intervention?

Answer 17

admit to the hospital for alcohol withdrawal

the patient is exhibiting the signs and symptoms of alcoholic withdrawal characterized by delirium, autonomic hyperactivity, perceptual distortions, and fluctuating levels of psychomotor activity. Seizures are a common occurrence prior to DTs, but the delirium may occur without preceding seizures. This is a medical emergency, and if untreated, it has a mortality rate of 20%

Question 18

A 28 yo male patient is being treated for depression and has been taking paroxetine (Paxil) for the past 2 and a half months with marked improvement. The patient reports problems with sexual functioning related to the medication. What is an immediate concern with abrupt discontinuation of the medication?

Answer 18

risk of drug withdrawal symptoms

the greatest risk of abrupt withdrawal of short-acting SSRIs is a withdrawal syndrome or withdrawal delirium which represents cholinergic rebound

Question 19

a 26 yo female has a long history of sexual promiscuity and substance abuse. She frequently expresses anger when she feels abandoned. She also has difficulty controlling her anger at times. her past relationships have been intense and short-lived. She has attempted suicide twice in the past 18 months. What disorder does she exhibit?

Answer 19

borderline personality

this is characterized by instability of interpersonal relationships, marked impulsivity that is potentially self-damaging, inappropriate, intense anger or control of anger, recurrent suicidal attempts, gestures or threats, and identity disturbances.

Question 20

What are the cluster B personality disorders that are clumped together as “Dramatic, Wild, Erratic, Impulsive, & Emotional”?

Answer 20

1. Antisocial Personality Disorder

• behavior’s deviating sharply from the norms, values & laws of society (harmful or hostile). may commit criminal acts with disregard to violation of rules

(may begin in childhood as conduct disorders but must be 18 or older to Dx)

2. Borderline Personality Disorder

unstable, unpredictable mood & affect. unstable self-image and relationships but cannot tolerate being alone. marked sensitivity to criticism and rejection. mood swings. black and white thinking (all good or all bad). impulsivity in self-damaging behaviors (suicide threats/attempts, substance abuse, reckless driving, spending)

3. Histrionic Personality Disorder

overly emotional, dramatic, seductive. “attention seeking”

self-absorbed temper tantrums, often inapprorpriate, sexually provocative, seductive. seek reassurance or praise often.

Question 21

What are the 3 cluster A personality disorders? clumped together as “social detachment with unusual behaviors: weird, odd, eccentric behavior”

Answer 21

1. schizoid personality disorder

pattern of voluntary social withdrawal and anhedonic introversion (constricted affect), indifferent to others, loner “hermit-like behavior”, little enjoyment in close relationships/sex

2. schizotypal personality disorder

odd, eccentric behavior & peculiar thought patterns suggestive of schizophrenia without psychosis (delusions), “odd” in behavior or appearance, inappropriate affect or speech, “magical thinking” (believes in clairvoyance, superstition, bizarre fantasies, etc.)

pervasive discomfort with close relationships

3. paranoid personality disorder

pervasive pattern of distrust & suspiciousness of others

distrust and suspiciousness: misinterprets the actions of others as melavolent, sees hidden messages and gets insulted

lack of interest in social relationships, bears grudges, doesn’t forgive, preoccupation with doubt regarding the loyalty of others

Question 22

a 19 yo woman has been consuming up to 6 beers daily since she was 16. she is now pregnant with her first child, has had little prenatal care, and is due to deliver in four weeks. What neonatal problem should you anticipate?

Answer 22

low birth weight

fetal alcohol syndrome is a common cause of low birth weight

Question 23

A patient is started on a new antipsychotic medication for his disorder. 3 days later he develops altered consciousness, lead-pipe rigidity, diaphoresis and catatonia. Vitals reveal RR 20, T 105.6, sats 95%. Which of the following would b the most appropriate initial intervention in this patient?

Answer 23

supportive care with fluids and antipyretics

neuroleptic malignant syndrome is characterized by extrapyramidal signs, BP changes, altered consciousness, hyperpyrexia, muscle rigidity, dysarthria, cardiovascular instability, fever, pulmonary congestion and diaphoresis. Controlling fever and fluid support are the best initial management.

A normal pulse ox–mechanical ventilation not indicated

Question 24

a patient tells you that he is receiving special messages from the TV every night at 7:00 pm. This is an example of which of the following:

Answer 24

ideas of reference

fixed beliefs that people are referring to you and about you through media

Question 25

25 yo female presents to ED after collapsing at work. Medical history significant for mood disorder that causes her to have “wild mood swings and reckless behavior” according to her husband. She was diagnosed a year ago and since has been treated with several meds. Her symptoms today consist of N/V, fatigue, tremor and hyperreflexia. Lab results show an elevated BUN and creatinine, low sodium and elevated drug levels. Which med is most likely causing her symptoms?

Answer 25

Lithium

any sodium loss results in increased lithium levels. Signs and Sx include vomiting, diarrhea which exacerbate the problem. Tremors, muscle weakness, confusion, vertigo, ataxia, hyperreflexia, rigidity, seizures and coma may also be present.

Question 26

Formications are most commonly associated with which of the following:

a. delusional disorder

b. adverse drug reaction

c. alcohol withdrawal

d. OCD

Answer 26

alcohol withdrawal

formications are the sensation of insects crawling on the skin and is commonly associated with delirium tremens from alcohol withdrawal and cocaine addiction

the Dx of delusional disorder requires the presence of nonbizarre delusions of at least 1 months duration that are not atrributed to another disorder

Question 27

Which of the following classes of antidepressants is associated with anticholinergic side effects, including cardiac disrhythmias, dry mouth, sedation, and orthostatic hypotension?

a. SSRIs

b. MAOIs

c. TCAs

d. atypical antidepressants

Answer 27

TCAs

TCAs have well known anticholinergic effects

Question 28

Which of the following is the treatment of choice for benzodiazepine intoxication?

Answer 28

flumazenil (ROMAZICON)

Question 29

a 25 yo male on behavioral medicine unit is given Haloperidol (HALDOL) IM for a violent psychotic outburts. Initially he quiets down, but about an hour later develops confusion, an inability to open his mouth, and a T of 40 degrees C. Initial treatment should consist of which med?

Answer 29

dantrolene

in addition to supportive treatment, the most commonly used medications for neuroleptic malignant syndrome are dantrolene (DANTRIUM) and bromocriptine (PARLODEL)

Question 30

What lab test must be monitored frequently in patients who are taking clozapine (CLOZARIL)?

Answer 30

white blood cell count

Leukopenia, granulocytopenia, and agranulocytosis occur in approxiamtely 1% of patients on this medication, clozapine should not be dispensed without proof of monitoring.

Question 31

what lab test should be followed routinely every 6 to 12 months in patients taking lithium?

Answer 31

TSH

Lithium induces hypothyroidism because of the decrease in concentration of circulating thyroid hormones

Question 32

differentiate between oppositional defiant disorder and conduct disorder

Answer 32

oppositional defiant disorder (ODD) is differentiated from conduct disorder by the lack of bullying and the lack of destruction to property. Many children with ODD do drift into conduct disorders over time. His good grades and conduct at school lessen the probability of untreated ADD. Personality disorders (antisocial personality disorder) cannot be diagnosed at this early an age.

Question 33

what is a dependent personality disorder?

Answer 33

these patients are constantly oseeking external support and will do even unpleasant things for others to gain approval and nurturing

Question 34

which of the following is the most appropriate management of acute psychosis in a patient with scizophrenia?

Answer 34

risperidone (RISPERDAL)

there are numerous options in the management of acute psychosis including benzodiazepines and antipsychotics such as haloperidol (first generation - typical - antipsychotic), risperidone or aripiprazole (second generation - atypical - antipsychotics)

Question 35

What class of medications has been found most beneficial in the treatment of alcoholism not associated with a concomitant psychiatric illness?

Answer 35

benzodiazepines

though no pharmacologic therapies have substantial supportive data in treating alcoholism not associated with a mood or anxiety disorder short term use of BZDs has the greatest benefit especially with acute cessation of alcohol (ativan protocol)